Building on foundational policy work by the Canadian Cardiac Transplant Network (CCTN), the Heart Transplant Advisory Committee (HTAC) led by Canadian Blood Services, developed policies outlining a consistent national approach that defines eligibility and prioritization of high status recipients in the interprovincial sharing of donor hearts At present, heart transplant programs in Canada are listing all transplant candidates in the Canadian Transplant Registry (CTR) but would also like to use the CTR to allocate hearts interprovincially to sensitized (>80% cPRA) and/or medically urgent (status 4) patients and improve the tracking of the outcomes of organ sharing in this patient population. The goals are to increase efficiencies in the system and improve transparency of interprovincial organ sharing of high status hearts.
Canadian Blood Services (CBS) has entered the final implementation phase of the Interprovincial Organ Sharing of Hearts for High-Status Recipients. Currently, heart transplant recipients of all statuses are continuing to be listed through the National Organ Waitlist (NOW), however allocation and offers for medically urgent and highly sensitized patients will be conducted through the CTR once the implementation is completed.
On July 22, 2021, the IPOS Heart program was released into the production environment of the CTR (release 5.0) and is ready to go live when stakeholders in all jurisdictions are ready to launch. The functionality to support the organ sharing program can be turned on without impacting the regular operation of the CTR.
The IPOS HSH project must go live simultaneously across Canada; a phased implementation is not possible due to potential data synchronization issues between various technical systems that could result in critical missed transplant opportunities. As a result, the go-live date for the program is highly dependent on the capacity of provincial partners to implement updates to their respective provincial systems.
All provinces originally committed to a go-live date in July however one stakeholder is transitioning to a new organ allocation system and has requested an extension in the launch timeframe to enable them to complete the transition to their new system as it must be fully implemented before they can participate in the heart sharing program.
Given the potential for cascading impacts of additional delays, other jurisdictions have indicated a preference to set the go live for Jan 2022, and accordingly, the decision has been made for the IPOS heart project to go live January 20, 2022.
To support our provincial partners through this transition, CBS has developed an IPOS HSH project website that provides project updates and includes a resource section with the latest versions of the approved policies, reference documents and frequently asked questions. The website can be accessed here.
Resource and training documents that can be found on the website include:
As per policy CTR10.003 Requirement to Offer, an offer of a donor heart must first be proposed to the #1 ranked recipient on the allocation list and all other status 4 recipients included on the list must also be notified of the offer. To this effect, the CTR will generate two notifications when an offer is made:
In addition to the above, it is recommended that the offering ODO make a verbal offer and notify ODOs of the other listed status 4 recipients via phone call. We acknowledge the nuances in workflow in different jurisdictions and the impact this could have on local processes. We encourage any concerns/questions regarding this be brought at the ODO/Physician group meetings that will be held in November (please see “next steps” below).
All ODOs are encouraged to also follow up with their local transplant programs to determine the impact on local processes/workflow such as:
As interprovincial heart sharing policies were developed in discussion with HTAC the decision was not to utilize any filters that would screen eligible HSH recipients based on height, weight, and other criteria available in the CTR. This would ensure physicians were able to have full line of sight into all offers.
Through ongoing engagement ODOs concern was expressed about the number of unnecessary phone calls and delays to allocation if basic physician prescribed donor acceptance criteria such as weight will not be used in IPOS HSH allocation.
After further discussion with physicians and the project implementation steering committee, it was recently decided to include a recipient’s acceptable minimum and maximum donor weight thresholds to the CTR matching algorithm; so as to reduce unnecessary offers and phone calls to recipient ODOs for whom the donor’s weight is a known contraindication to transplant. When the HSH algorithm is run on a donor, any recipients who are not willing to accept the weight of this donor will be left off the donor’s allocation results list.
As the minimum and maximum donor weight acceptance fields already exist in current web service methods and the CTR, we are hopeful the impact of integrating this functionality in local jurisdictions will be of minimal impact.
An amendment to policy CTR 10.002 – Heart Allocation, will be completed after go-live in January 2022 to align to the above.
The ‘Days at Current Medical Status’ (DCMS) is a tier in the HSH allocation tie-breaking rules that the CTR is to use to produce a ranked list of IPOS HSH recipients who have matched the heart donor. Organ offers are made first to the recipient (s) who have ranked first on the list, then subsequently to lower ranked recipients. Guidelines have been developed in discussion with HTAC and are aimed at providing direction in the calculation of the eligible days at current medical status. The reference document can be found here.
As a reminder of the rank at which Days at Current Medical Status (DCMS) is incorporated please refer to the flow chart below:
1. Heart first goes through Status 4 recipients including highly sensitized status 4 recipients
2. If multiple Status 4 recipients are listed, then the tiebreaking ranking would proceed as follows:
|a. Donor <19 years & Recipient < 19 years old||Rank 1|
|b. Pediatric recipient <19 years of age||Rank 2|
|c. Number of days listed at Current medical Status||Rank 3|
|d. Donor / Recipient in the same region||Rank 4|
3. If no match or allocation within the status 4 patients (if any), the heart is then offered nationally through highly sensitized recipients with a hemodynamic status of 3.5 and below: nationally
|a. Donor <19 years & Recipient < 19 years old||Rank 1|
b. Higher cPRA ranked above lower cPRA
|c. Pediatric recipient <19 years of age||Rank 3|
d. Medical Status
|e. Number of days listed at current medical status||Rank 5|
|f. Donor and Recipient are in the same region||Rank 6|
DCMS starts to accrue at the time a recipient becomes eligible for the IPOS HSH program (i.e. – status 4 or > 80% cPRA).
For further assistance in calculating the days at current medical status for a recipient, please call CBS’ customer support line (available 24 hours, 7 days a week) at 1-855-287-2889.
In discussion with HTAC a need was identified to establish a process that would allow a physician to recuse a highly sensitized recipient (> 80% cPRA) from participating in the IPOS HSH program if deemed medically appropriate.
If such a request is received the process outlined in the document “Allocation, Offer Management, Notification and Recusal Process” found on the IPOS HSH Project website should be followed.
Please note the both the Patient Recusal Form and the Patient Reinstatement Form will need to be signed by a designated representative of the recipient’s transplant program before submitting to CBS customer support. We encourage ODOs and local transplant programs to develop an internal process to gain authorization for either recusing or reinstating a recipient.
This process can only be used for highly sensitized patients. If a physician expresses the need to recuse a medically urgent (status 4) recipient from national sharing, the notes section in the CTR should be used.
Further discussion and education leading up to go live will be provided at three venues:
For any questions or concerns, please contact the CBS team at firstname.lastname@example.org.